Physio Point, Physiotherapy

Just published 🔥

Systematic review and meta-analysis of predictive factors for spontaneous regression in lumbar disc herniation 💡

👉Relatively little evidence exists on predictive factors for the spontaneous regression of lumbar disc herniation (LDH), although it is a well-documented phenomenon. Without specific intervention, two-thirds of patients can expect disc regression, with 85% attaining symptom resolution within 1 year. https://brjp.org.br/article/doi/10.5935/2595-0118.20210067, https://pubmed.ncbi.nlm.nih.gov/28072796/

❓ But which patients can expect such a regression?

📊In a brand-new systematic review Rashed and colleagues included 16 studies describing 360 cases of lumbar disc herniation regression. The majority tended to be younger and male and presented with radiculopathy and L4–5 or L5–S1 disc herniation. The mean time to follow-up imaging was 11.5 months, and MRI was used as the imaging modality for all. https://thejns.org/spine/view/journals/j-neurosurg-spine/aop/article-10.3171-2023.6.SPINE23367/article-10.3171-2023.6.SPINE23367.xml

📊The probabilities of spontaneous regression with bulging, protruded, extruded, and sequestered discs (definition and figure, s. below) were:

👉 Bulging: 13.3%
👉 Protruded: 52.5%,
👉Extruded: 70.4%, and
👉 Sequestered: 93.0%, respectively.

📌 Extruded and sequestered discs were also significantly more likely to completely regress than smaller morphologies.

Other predictors of regression were:

👉 Larger baseline herniation volume (1260.16 vs 1006.71 mm3, p < 0.002),

👉 transligamentous herniation (herniations that had perforated through the posterior longitudinal ligament, PLL, p < 0.001), and

👉 higher Komori types (stronger migrating of disc herniation, p < 0.001).

❓ What are the proposed mechanisms?

💡 A number of mechanisms for spontaneous regression have been proposed, but the most supported theory is that of on autoimmune response to herniated disc fragments in the epidural space promoting neovascularization, macrophage infiltration, and ultimately phagocytosis of disc material. https://pubmed.ncbi.nlm.nih.gov/36722839/, https://pubmed.ncbi.nlm.nih.gov/35999644/

💡 It is thought that this response is exaggerated in the presence of a sequestered fragment, which is why PLL rupture is associated with regression. https://pubmed.ncbi.nlm.nih.gov/36722839/

❓ What about the relationship to symptoms?

👉 The association between symptoms and LDH regression is less well defined in the literature but is generally assumed to be positive. This was demonstrated in all qualitative studies in this review as well as in the majority of those in the previous review. https://pubmed.ncbi.nlm.nih.gov/25009200/
More interestingly, the authors describe 2 papers that show significantly increased disc regression on MRI if symptoms have been present for a shorter duration (< 1 year vs > 1 year). https://pubmed.ncbi.nlm.nih.gov/29945407/, https://pubmed.ncbi.nlm.nih.gov/34323452/

📌 This finding correlates with the improved outcomes seen with shorter symptom duration (< 12 months) in both surgical and non-surgical cohorts in the largest trials to date. https://pubmed.ncbi.nlm.nih.gov/22012528/

Classification of disc herniation: https://pubmed.ncbi.nlm.nih.gov/24768732/

A BULGING DISK refers to the generalized or focal extension of disc tissue, usually < 3 mm from the vertebral body apophysis, and is considered a normal variant.

A PROTRUDED DISK extends > 3 mm beyond the apophysis, but importantly, its herniated dimen-sions do not exceed those of the remaining disc within the disc space.

This is unlike EXTRUDED DISKS, in which at least one plane of herniated disc tissue exceeds disc space dimensions and usually extends through the posterior longitudinal ligament (PLL).

A SEQUESTRED DISK is a variant of extruded discs whereby a portion of the disc fragment is displaced beyond the outer annulus and maintains no connection with the origin disc tissues.

MIGRATED DISKS are those with extruded segments displaced away from the outer annulus and can be extruded or sequestered in morphology.

Illustration: https://www.nejm.org/doi/pdf/10.1056/nejmcp1512658

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Plan ahead for 2024! Registration is now open for the WCSPT in Oslo, Norway, June 14-15, 2024!

Get the details and register here: https://www.WCSPT.ORG

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Thank you Bucharest!

Ready and set for tomorrow! OMTRO 1st congress, an honor to be invited as a speaker. 1.500 registrants and counting!

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Gratis hand exercise ideas!!

Tip of the Week Tuesday!

I like using my leftover orthotic material to create these quick and easy-to-make tools. (Photos in the comments.) I give them to my patients to help improve end range straight fist, end range hook fist, end range finger flexion for a specific finger, all three pinch strength or end range finger flexion.

I can make the barrel larger or smaller depending on how much motion the patient currently has. I can increase resistance by changing the color of the sports cord. It's also great for isometric strengthening for the wrist and for biceps or triceps strengthening. It's very versatile and cheap to make. I have our office staff make several sizes and resistances in advance so they are available to give to PTs as they need it. I include the handouts by circling the specific exercise for them to perform. — Donna Hart Goodson, OTR/L, CHT

This is a VERY good article on obesity. Really interesting and insightful, especially for the non obese and clinicians

Everything You Know About Obesity Is Wrong For decades, the medical community has ignored mountains of evidence to wage a cruel and futile war on fat people, poisoning public perception and ruining millions of lives. It's time for a new paradigm.

Low Back Pain - clinical practice guidelines

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